UnitedHealthcare Community Plan is a Managed Care Organization (MCO) committed to bringing you and your family quality healthcare when you need it most. We provide Medicaid services to UnitedHealthcare members. We are a health insurance plan that coordinates your Virginia Medicaid coverage. As a member, you and your regular doctor, also called a Primary Care Provider (PCP) will work together to help keep you healthy and care for your health problems. UnitedHealthcare helps you get quality healthcare.
When you apply for Medical Assistance, you are screened for all possible programs based on your age, income, and other information. To be eligible for a Medical Assistance Program, you must meet the financial and non-financial eligibility conditions for that program. Please visit the Virginia Department of Social Services’ (VDSS) Medicaid Assistant Program page for eligibility details and/or VDSS Medicaid Forms and Applications page for application and other Medicaid form details.
FAMIS is Virginia’s health insurance program for children of eligible families including those who meet one of the following categories:
- Children under age 21
- Foster Care and Adoption Assistance Child under age 26
- Pregnant women including two months post delivery
- Parent Care-Takers
Medicaid eligible persons who do not meet certain exclusion criteria must participate in the program. Enrollment is not a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program.
It is the policy of UnitedHealthcare Community Plan to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a Member you have certain rights. You have the right to:
- Receive timely access to care and services;
- Take part in decisions about your health care, including your right to choose your providers from UnitedHealthcare Community Plan network providers and your right to refuse treatment;
- Choose to receive long term services and supports in your home or community or in a nursing facility;
- Confidentiality and privacy about your medical records and when you get treatment;
- Receive information and to discuss available treatment options and alternatives regardless of cost or benefit presented in a manner and language you understand;
- Get information in a language you understand - you can get oral translation services free of charge;
- Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services;
- Receive information necessary for you to give informed consent before the start of treatment;
- Be treated with respect and dignity;
- Get a copy of your medical records and ask that the records be amended or corrected;
- Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to you or others or when there is a specific medical necessity. Seclusion and restraint will never be used a s a means of coercion, discipline, retaliation, or convenience;
- Freely exercise rights so long as that exercise does not adversely affect the way UnitedHealthcare Community Plan and its providers treat you;
- Get care without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status or religion;
- Be informed of where, when and how to obtain the services you need from UnitedHealthcare Community Plan, including how you can receive benefits from out-of-network providers if the services are not available in UnitedHealthcare Community Plan’s network
- Complain about UnitedHealthcare Community Plan to the State. You can call the Helpline at 1-800-643-2273 to make a complaint about us.
- Appoint someone to speak for you about your care and treatment and to represent you in an Appeal;
- Make advance directives and plans about your care in the instance that you are not able to make your own health care decisions. See section 14 of your handbook for information about Advance Directives.
- Change your health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference section 2 of your handbook or call the Managed Care Helpline at 1-800-643-2273 (TTY: 1-800-817-6608) or visit the website at virginiamanagedcare.com for more information.
- Appeal any adverse benefit determination (decision) by UnitedHealthcare Community Plan that you disagree with that relates to coverage or payment of services. See Your Right to Appeal in section 15 of your handbook.
- File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in section 15 of your handbook.
- To receive information from us about our plan, your covered services, providers in our network, and about your rights and responsibilities.
- To make recommendations regarding our Member rights and responsibility policy, for example by joining our Member Advisory Committee (as described later in this section of your handbook.)
As a Member, you also have some responsibilities. These include:
- Present your UnitedHealthcare Community Plan Membership card whenever you seek medical care.
- Provide complete and accurate information to the best of your ability on your health and medical history.
- Follow plans instructions for care that you have agreed to with your practitioners.
- Participate in your care team meetings, develop an understanding of your health condition, and provide input in developing mutually agreed upon treatment goals to the best of your ability.
- Keep your appointments. If you must cancel, call as soon as you can.
- Receive all of your covered services from UnitedHealthcare Community Plan’s network.
- Obtain authorization from UnitedHealthcare Community Plan prior to receiving services that require a service authorization review (see section 14).
- Call UnitedHealthcare Community Plan whenever you have a question regarding your Membership or if you need assistance toll-free at one of the numbers below.
- Tell UnitedHealthcare Community Plan when you plan to be out of town so we can help you arrange your services.
- Use the emergency room only for real emergencies.
- Call your PCP when you need medical care, even if it is after hours.
- Tell UnitedHealthcare Community Plan when you believe there is a need to change your plan of care.
- Tell us if you have problems with any health care staff. Call Member Services at one of the numbers below.
- Call Member Services at one of the phone numbers below about any of the following:
- If you have any changes to your name, your address, or your phone number. Report these also to your case worker at your local Department of Social Services.
- If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation.
- If you have any liability claims, such as claims from an automobile accident.
- If you are admitted to a nursing facility or hospital
- If you get care in an out-of-area or out-of-network hospital or emergency room
- If your caregiver or anyone responsible for you changes
- If you are part of a clinical research study.
If you are not satisfied with a decision we made about your service authorization request, or if we fail to respond timely to an authorization request, you have 60 calendar days from the date on the adverse benefit determination notice. You can do this yourself or ask your authorized representative to file the appeal for you. You can call Member Services at one of the numbers below if you need help filing an appeal or if you need assistance in another language or require an alternate format.
You can file the appeal as a standard appeal or an expedited (fast) appeal request by phone or in writing. You must follow up your standard appeal filed by phone with a signed, written appeal.
You or your doctor can ask to have your appeal reviewed under the expedited process if you believe your health condition or your need for the service requires an expedited review. Your doctor will have to explain how a delay will cause harm to your physical or behavioral health. If your request for an expedited appeal is denied we will tell you and your appeal will be reviewed under the standard process. We will not treat your provider unfairly because he or she helped you file an appeal.
Send your Appeal request to:
UnitedHealthcare Community Plan Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131-0364
If you make your standard appeal by phone, it must be followed up in writing. Expedited process appeals submitted by phone do not require you to submit a written request.
Your Right to File a Grieveance (Complaint)
UnitedHealthcare Community Plan will try its best to deal with your concerns as quickly as possible to your satisfaction. Depending on what type of concern you have, it will be handled as a grievance (complaint) or as an appeal.
What Kinds of Problems Should be Complaints
The grievance process is used for concerns related to quality of care, waiting times, billing and financial issues and customer service. Here are examples of the kinds of problems handled by the UnitedHealthcare Community Plan’s complaint process.
Grievances about quality
- You are unhappy with the quality of care, such as the care you got in the hospital.
Grievances about privacy
- You think that someone did not respect your right to privacy or shared information about you that is confidential or private.
Grievances about poor customer service
- A health care provider or staff was rude or disrespectful to you.
- UnitedHealthcare Community Plan staff treated you poorly.
- UnitedHealthcare Community Plan is not responding to your questions.
- You are not happy with the assistance you are getting from your Care Coordinator.
Grievance about accessibility
- You cannot physically access the health care services and facilities in a doctor or provider’s office.
- You were not provided requested reasonable accommodations that you needed in order to participate meaningfully in your care.
Grievance about communication access
- Your doctor or provider does not provide you with a qualified interpreter for the deaf or hard of hearing or an interpreter for another language during your appointment.
Grievance about waiting times
- You are having trouble getting an appointment, or waiting too long to get it.
- You have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other UnitedHealthcare Community Plan staff.
Grievance about cleanliness
- You think the clinic, hospital or doctor’s office is not clean.
Grievance about communications from us
- You think we failed to give you a notice or letter that you should have received.
- You think the written information we sent you is too difficult to understand.
- You asked for help in understanding information and did not receive it.
To make a grievance, call Member Services at the number below. You can also write your grievance and send it to us. If you put your grievance in writing, we will respond to your grievance in writing. You can file a grievance in writing, by mailing or faxing it to us at: UnitedHealthcare Community Plan Grievance Department
P.O. Box 31364
Salt Lake City, UT 84131-0364
So that we can best help you, include details on who or what your grievance is about and any information about your grievance. UnitedHealthcare Community Plan will review your grievance and if needed request any additional information. You can call Member Services at the number below if you need help filing a grievance or if you need assistance in another language or format.
We will notify you of the outcome of your complaint within a reasonable time, but no later than 30 calendar days after we receive your grievance or as quickly as your health condition requires..
If your complaint is related to your request for an expedited appeal, we will respond within 24 hours after the receipt of the complaint.
You Can File a Complaint with the Managed Care Helpline
You can make a complaint about UnitedHealthcare Community Plan to the Managed Care Helpline at 1-800-643-2273 (TTY: 1-800-817-6608) Monday – Friday, 8:30 a.m. – 6 p.m.
You Can File a Grievance (Complaint) with the Office for Civil Rights
You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information.
Office of Civil Rights- Region III
Department of Health and Human Services
150 S Independence Mall West Suite 372
Public Ledger Building
Philadelphia, PA 19106
If we do not tell you our decision about your appeal on time, you have the right to appeal to the State through the State Fair Hearing process. An untimely response by us is considered a valid reason for you to appeal further through the State Fair Hearing process.
We will tell you and your provider in writing if your request is denied or approved in an amount less than requested. We will also tell you the date of our decision, reason for the decision. And we will explain your right to appeal through the State Fair Hearing Process if you do not agree with our decision.
Your Right to a State Fair Hearing
If you disagree with our decision on your appeal request, you can appeal directly to DMAS within 120 calendar days from the date of our decision. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in your handbook. The State requires that you first exhaust (complete) UnitedHealthcare Community Plan appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely DMAS will count this as an exhausted appeal.
Standard or Expedited State Fair Hearings
You may file a State Fair Hearing with DMAS when you disagree with our appeal decision or believe we have not resolved your appeal timely. For, appeals that will be heard by DMAS you will have an answer generally within 90 days from the date you filed your appeal with UnitedHealthcare Community Plan. The 90 day timeframe does not include the number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor.
You can give someone like your PCP, provider, friend, or family member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.
Where to Send the State Fair Hearing Request
You or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final appeal decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS.
You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the internet at http://www.dmas.virginia.gov/Content_atchs/forms/dmas-200.pdf. You should also send DMAS a copy of the letter we sent to you in response to your appeal.
You must sign the State Fair Hearing request and send it to:
Department of Medical Assistance Services
600 E. Broad Street
Richmond, Virginia 23219
Fax: (804) 452-5454
Standard and expedited State Fair Hearing may also be made by calling (804) 371-8488
For FAMIS members, you may appeal our decision to the External Review Organization at:
2810 N. Parham Rd, Suite #305
Henrico, VA 23294
After You File Your State Fair Hearing Appeal
DMAS will notify you of the date, time, and location of the scheduled hearing. Most hearings can be done by telephone.
State Fair Hearing Timeframes
Expedited State Fair Hearing
If you qualify for an expedited appeal, DMAS will give you an answer to your appeal If DMAS decides right away that you win your appeal, they will send you their decision. If DMAS does not decide right away, you will have an opportunity to participate in a hearing to present your position. Hearings for expedited decisions are usually held within one or two days of DMAS receiving the letter from your doctor. DMAS still has to give you an answer within 72 hours of receiving your doctor’s letter.
Standard State Fair Hearing
If your request is not an expedited appeal, or if DMAS decides that you do not qualify for an expedited appeal, DMAS will give you an answer within 90 days from the date you filed your appeal with DMAS. UnitedHealthcare Community Plan. The 90 day timeframe does not include the number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. You will have an opportunity to participate in a hearing to present your position before a decision is made.
Continuation of Benefits
In some cases you may be able to continue receiving services that were denied by us while you wait for your State Fair Hearing appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal:
- Within 10 calendar days of the plan sending the notice of adverse benefit from being told that your request is denied or care is changing;
- By the date the change in services is scheduled to occur. The intended effective date of the plan’s proposed adverse benefit determination.
Your services will continue until you withdraw the appeal, the original authorization period for your service ends, or the State Fair Hearing Officer issues a decision that is not in your favor. You may, however, have to repay UnitedHealthcare Community Plan for any services you receive during the continued coverage period if UnitedHealthcare Community Plan’s adverse benefit determination is upheld and the services were provided solely because of the requirements described in this section.
If the State Fair Hearing Reverses the Denial
If services were not continued while the State Fair Hearing was pending
If the State Fair Hearing decision is to reverse the denial, UnitedHealthcare Community Plan must authorize or provide the services under appeal as quickly as your condition requires and no later than 72 hours from the date UnitedHealthcare Community Plan receives notice from the State reversing the denial.
If services were provided while the State Fair Hearing was pending
If the State Fair hearing decision is to reverse the denial and services were provided while the appeal is pending, UnitedHealthcare Community Plan must pay for those services, in accordance with State policy and regulations.
If You Disagree with the State Fair Hearing Decision
The State Fair Hearing decision is the final administrative decision rendered by the Department of Medical Assistance Services. If you disagree with the Hearing Officer’s decision you may appeal it to your local circuit court.